CLM-2026-023549
Meadow Primary Care Associates, Family Medicine. Service 2026-08-09 at office (POS 11). Received 2026-09-15.
Member
Resolved through the identity graph
- Member
- Henry Walsh
- Member ID
- UHC-89689-34
- Date of birth
- 1949-08-27
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-415751
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-5396
- Coverage period
- 2021-01-01 to present
- Deductible
- $291.19 of $2,500.0012%
- Out-of-pocket maximum
- $1,849.15 of $5,000.0037%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 9704343703
- Network
- In network
- Rendering NPI
- 5365628978
- Location
- Tampa, FL · TIN 74-5049309
- Authorisation / referral
- none / none
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 36415 | Venipuncture | — | 1 | 1 | $15.00 | $9.30 | $9.30 | $0.00 | Paid |
| 2 | 99214 | Office visit, established patient, moderate complexity | 25 | 1 | 1 | $204.00 | $126.48 | $0.00 | $126.48 | Paid |
| Totals | $219.00 | $135.78 | $9.30 | $126.48 | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-187528
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-012277 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-08-09: NULL (PPO), effective 2021-01-01. | |
| Timely filing | Pass | Received 37 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Meadow Primary Care Associates (9704343703). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Meadow Primary Care Associates2026-08-09 18:18
Follow-up for encounter for general adult medical examination without abnormal findings. Plan discussed, medications reconciled. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-09-15 02:32
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-187528.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-017689 | 2026-07-21 | Lakeside Bone and Joint Center | $457.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Authorisation must be confirmed with UM before payment.